Anemia Mukt

Bharat
-An Intensified National
Iron Plus Initiative

18th September, 2018

Ministry of Health and Family Welfare
Government of India
A Snapshot of Anemia in India v

100
8074 69.4 High Prevalence
Trend in 58.5 Children
Prevalence of 60
52 55.2 53.1 WRA (15-49 across all ages
Anemia among
40 yrs)
Children and
Women 20 Slow progress in
0 most of the States
NFHS 2 NFHS 3 NFHS 4

58% 54% 29% 53% 50% 58%

of children of adolescent of adolescent of women in their of pregnant women of breastfeeding

(6-59 months) girls boys reproductive age mothers

(15-19 years) (15-19 years)

Anemia Prevalence among Pregnant Women
(NFHS-4) v

Anemia prevalence
among Pregnant Women States/ UTs
(15-49 yrs)

11 States and 2 UTs

More than 50% Bihar, Himachal Pradesh, Jharkhand, Madhya Pradesh, Uttar Pradesh, Meghalaya
Tripura, Andhra Pradesh, Gujarat, Haryana, West Bengal
A & N islands and D & N Haveli

10 States and 1 UT
40% to 50% Chattishgarh, Odisha, Rajasthan, Uttarakhand, Assam, Karnataka, Maharashtra,
Punjab, Tamil Nadu, Telangana
Delhi

8 States and 2 UTs

Less than 40% Jammu & Kashmir, Arunachal Pradesh, Manipur, Mizoram, Nagaland, Sikkim,
Goa, Kerala
Lakhwadeep and Puducherry
v
Causes of High Burden of Anemia
Low Iron Maternal
Dietary Iron Loss
Stores Anemia
• During pregnancy in • Inappropriate IYCF • Due to parasitic load • Increased iron
anemic mothers esp. Complementary (malaria, intestinal requirement due to
Feeding Practices worms) tissue, blood
• Poor iron stores formation and
from infancy, • Excessive • Poor environmental energy requirement
childhood consumption of ‘Iron sanitation, unsafe during pregnancy
deficiencies and Inhibitors’ (tea, drinking water and
adolescent Anemia coffee, calcium-rich inadequate personal • Iron loss from post-
foods) and low hygiene partum
intake of ‘Iron haemorrhage
Enhancers’ (Vitamin
C etc.) • Teenage pregnancy

• Low bioavailability of • Repeated

dietary iron pregnancies with
• 50% of the less than 2 years
population is interval
consuming < 50%
Public Health Implications of Anemia v

• Decreased work output and work capacity

Reduced physical development • Physical and cognitive losses due to IDA in South Asia are staggering:
close to $ 4.2 billion annually in Bangladesh, India and Pakistan
Impact on pregnancy outcomes
• About 20 % of maternal deaths are caused by Anemia worldwide
• tube defects, infants of low birth weight and still births
Reduced cognitive development • AnemiNeuralc pregnant women are more prone to increased morbidity
and ; there is a three times greater incidence of premature delivery in
severely anemic women
Economic impact
• Diminished concentration, disturbance in perception, delayed
psychomotor development
• Impaired language and motor skills,
• Diminished IQ equivalent to a 5–10 point

• In the WHO/World Bank rankings, Iron Deficiency Anemia is the

third leading cause of DALYs lost for females aged 15–44 years and
1.18 % of Gross Domestic Product (GDP) loss. Median total loss
(physical and cognitive) combined are 4.05% of GDP in developing
countries.
Why Should We Address Anemia? v

Short term, Long term and Intergenerational benefits

Enhances
Improvements
Contribute to a health &
virtuous cycle by
enhance human
fostering economic nutrition of
capital
development women and
children
World Health Assembly has proposed a target of 50% reduction in Anemia
among women by 2025 and
NHP 2017 commits to reduce anemia prevalence by 3% per year
Annual average rate of reduction (AARR) of anemia prevalence
Current – close to 1% Committed to achieve target – 3%
 Milestones in Control of Anemia in India v

• Anemia control efforts in India started in 1970 with

supplementation of Iron and folic acid across age groups
• Anemia level in various population groups remained high
• IFA coverages remained less than 30% 2018
• More than 50% cases of anemia 2013
attributed to Iron deficiency
2007
I-NIPI Program
1991 Wkly and biwkly
intensification
(Anemia Mukt Bharat)
supplementation. PLW 60mgX180 days,
1970 Test and treat (NIPI) IFS for WRA 6X6X6
5-10 yrs age group strategy
Life cycle approach
added Life cycle approach

60 mg Iron
changed to
100mg
60 mg Iron supplementation
for PW and 20 mg for
1-5 yr X100 days
Learning from Best Performing
States/ Districts v

De c adal c hang e |
Eig ht s tate s >=30% de c line (6 are e as te rn s tate s )
Two S tate s >=25% inc re as e
55
45
35
25
15
5 - 9 % d e c lin e 1 4 - 2 8 % d e c lin e > = 3 0 % d e c lin e
%de cline

5
-5
-15
-25
-35
-45
55
65

compa ring NFHS -4,2015-16 AND NFH-3,2005-06

States with >=30% Anemia Decline
What Did They Do? v
 Anemia Mukt Bharat
v

Anemia Mukt Bharat 6

will use a 6x6x6
strategy to
combat anemia 6X6X6
strategy
6
6 institutional
interventions mechanisms
Six Beneficiaries
v

124
million
Children
17 (6-59 months)
134
million
Estimated
women of
reproductive children
age (5-9 years)
(20-24 years) 6
450 million
27 115
beneficiaries
Reaching nearly 50% of
million
the country’s population
million
adolescent boys
lactating
and girls
mothers
30 (10-19 years)

million
pregnant
women
Beneficiary-wise Targets
v

Anemia reduction targets for 2022

Ane mia pre vale nc e (%)

To reduce Bas e line
the Ag e g ro up (NFHS 4) Natio nal targ e t 2022
prevalence Children 6–59 months 58 40
of anemia
Adolescent girls 15–19 years 54 36
by 3
percentage Adolescent boys 15–19 years 29 11
points per
Women of reproductive age 53 35
annum
Pregnant women 50 32

Lactating women 58
Six Interventions
v

2
1
Prophylactic iron folic acid P eriodic deworming of children,
supplementation adolescents, pregnant women

4
3 Intensified year-round Behavior
Change Communication T esting of anemia using digital
HOSPITAL

Campaign Solid Body Smart methods and point of care

Mind ,delayed cord clamping treatment

6
5 Addressing non-nutritional causes
ANGANWADI Mandatory provision of iron
of anemia in endemic pockets,
public health programmes with special focus on malaria,
haemoglobinopathies and fluorosis
Intervention- 1
Prophylactic IFA supplementation- Regime
v

Age group Dose

6 – 59 months • Biweekly, 1 ml Iron and Folic Acid syrup

of age • Each ml of Iron and Folic Acid syrup containing 20 mg elemental Iron +
100 mcg of Folic Acid
• Bottle (50ml) to have an ‘auto-dispenser’ and information leaflet as per
MoHFW guidelines in the mono-carton

5- 10 years • Weekly, 1 Iron and Folic Acid tablet

children • Each tablet containing 45 mg elemental Iron + 400 mcg Folic Acid
• Sugar-coated, pink colour
Cont...
Prophylactic IFA Supplementation- Regime
v
Age group Dose
Adolescent • Weekly, 1 Iron and Folic Acid tablet
• Each tablet containing 60 mg elemental iron + 500 mcg Folic Acid
girls and boys,
• Sugar-coated, blue colour
10-19 years of age
Women of • Weekly, 1 Iron and Folic Acid tablet
• Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid,
reproductive age • sugar-coated, red colour
(non-pregnant,
non-lactating) All women in the reproductive age group in the pre-conception period and up
to the first trimester of the pregnancy are advised to have 400 mcg of Folic
20-49 years Acid tablets, daily
Pregnant women and • Daily, 1 Iron and Folic Acid tablet starting from the fourth month of
pregnancy (that is from the second trimester), continued
lactating mothers
• Throughout pregnancy (minimum 180 days during pregnancy)
(0-6 months child) • To be continued for 180 days, post-partum
• Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid
• Sugar-coated, red colour
 Intervention 3
Intensified 360 Degree IEC/ BCC for Anemia Prevention
v
& BehaviourChange

Focus on Social mobilization and behaviour change: 4 key behaviours

1. Compliance to Iron Folic Acid supplements and deworming
2. Appropriate Infant and Young Child Feeding (IYCF)
3. Increase intake of iron-rich, protein-rich and vitamin C rich foods
through diet diversification and consumption of fortified foods.
4. Practice of delayed cord clamping in all health facility deliveries
followed by early initiation of breastfeeding within 1 hour of birth
Solid Body,
Smart Mind
Intervention 4
Test and Treat Strategy v

Testing:
 Use of digital hemoglobinometers
 In two age groups- to begin with
 School-going Adolescent girls and boys 10-19 years, WIFS
beneficiaries, using RBSK mobile teams
 Pregnant women at all ANC contact points.
 At all high case load facilities at block level and above,
hemoglobin level estimation will be done using Semi-Auto
Analyzers
 This may be extended to all age groups, later
Anemia Management Protocol for
Adolescents v

Mild/moderate
First level of treatment Two IFA tablets (each with 60 mg elemental iron and 500 mcg
(at all levels of care) folic acid), once daily, for 3 months
Line listing of all anemic cases; Two Follow-ups
• First follow-up after 45 days and second follow-up after 90
days at nearest health facility
• If hemoglobin levels have come up to normal level, discontinue
the treatment and continue with the prophylactic IFA dose
If no improvement after first If no improvement after three months of treatment, RBSK team
level of treatment will refer the adolescent to First Referral Unit (FRU)/District
Hospital (DH)
Severe anemia Management to be done by medical officer at FRU/DH based on
investigation and diagnosis
Anemia Management Protocol
forPregnant Women v

Mild/moderate

First level of treatment Two tablets of iron and folic acid tablet (60 mg elemental iron and
(at all levels of care) 500 mcg folic acid) daily, orally given by the health provider
during the ANC contact.

* Parental iron (IV Iron sucrose or Ferric Carboxy Maltose may be

considered as the first line of treatment in pregnant women who
are detected to be anemic late in pregnancy or in whom
compliance is likely to be low (high chance of lost to follow-up).

Follow-up Every two months, during the ANC contact

If no improvement after first If no Hb (<1g/dl) increase; Refer to FRU/DH (case may be

level of treatment managed with IV Sucrose/FCM)

Severe anemia (5-6.9 g/dl) By medical officer, using IV Sucrose/FCM. Immediate

Management protocol for severe anemia contraindicated for patients of thalassemia major and sickle cell disease.
hospitalization if pregnant woman is in 3 rd trimester.
Six Institutional Mechanisms
v

Intra-ministerial National Anemia Mukt

1 2 Bharat Unit
coordination

National Centre
of Excellence and Convergence with
3 4 other ministries
Advanced Research on
Anemia Control

Anemia Mukt Bharat

Strengthening supply dashboard and digital
5 chain and logistics 6 Portal - one-stop shop
for anemia
Target based monitoring
SIX performance indicators v

Percentage of states/districts with

Percentage of children 6–59 months who
available stocks of IFA for all age
received at least8 doses of IFA syrup
groups (HMIS 19.6, 19.7, 19.8, 19.9)
(HMIS 9.9)

Percentage of school-going adolescents

Percentage of women of reproductive age
10–19 years (girls and boys), eligible under
20–24 years, eligible under Mission ParivarVikas,
WIFS programme, who received at least
who received at least4 red IFA tablets(NEW)
4 blue IFA tablets(HMIS 22.1.1)

Percentage of school children 5–9 years Percentage of eligible pregnant women

who received at least4 pink IFA tablets who received at least180 IFA tablets
(HMIS 23.1) during antenatal contact point (HMIS 1.2.4)
What’s New?
v

Coordinated management efforts – intra & inter ministerial

Target based monitoring and KPI reviews and awards; Private

schools; 60 mg instead of 100 mg prophylactic dose, sugar coated.

Communication materials for extensive awareness, intensive 360

degree communication campaigns - Creating a Jan Andolan…

Use of digital methods of hemoglobin estimation and point of care

treatment, newer treatment strategies – IV Iron Sucrose and FCM

Linkage with Malaria; mandating use of fortified food in public

health programmes, specially double fortified salt (iron and iodine)

Linkage with academic – national and regional networks- (re)

learning and policy decisions
 LET US MAKE
INDIA ANEMIA-FREE